Thursday, October 14, 2021

DENSE BREAST DETECTION & IMAGE GUIDED ONCOLOGIC TREATMENT

By: Robert L. Bard, MD & Noelle Cutter, PhD   |  Edited by: Lennard M. Gettz, Ed.D

PROLOGUE

In 2014, Imaging Technology News (ITN) introduced breast cancer survivor-turned-crusader Dr. Nancy Cappello and her story about having dense breast tissue leading to a late-stage cancer.  A false negative mammography scan (diagnosed in 2004) concealed a large 2.5 cm suspicious lesion, which was later confirmed to be stage 3c breast cancer.  This same cancer had metastasized to 13 lymph nodes. This sparked Dr. Cappello to create the "Are You Dense?" Foundation- an international awareness crusade to better support dense breast diagnostics and initiatives pass legislation to enact laws requiring mammography centers to inform patients about their breast density and the associated cancer risks. Dr. Cappello passed away on Nov 15, 2018, from secondary myelodysplastic syndrome (MDS), a bone marrow cancer that was a complication of her prior aggressive breast cancer treatments.  But she ignited a legacy of fighting for improved policies, imaging technologies and advanced research to better address this health crisis that puts the est. 40% of the female population (women with dense breasts) at risk of a false negative reading.


PART 1: USE OF ULTRASOUND IN A 2021 RESEARCH STUDY OF BREAST DENSITY

In an ongoing clinical study co-investigated by Dr. Robert Bard (NYC) and Dr. Noelle Cutter (of Molloy College, Long Island, NY), data is collected from a cohort of women undergoing ultrasound density scans. Inspired by Dr. Cappello’s early surveys of specific demographic groups, this 2021 research explores dense breast predominance in the younger population or those with lower body mass index (including dancers and athletes), both are likely candidates to receive false negative readings on a mammogram.  

In addition, breast density is also associated with breast cancer risk in women between ages 40-65, but there is limited evidence of its association with risk of breast cancer among women 18+.   This estimated proportion of breast cancers are attributable to breast cancer risk factors commonly documented in clinical practice and used in breast cancer risk prediction models, including BI-RADS breast density and ultrasounds to confirm mammography readings.  


Target Objectives

Endurance athletes are to be defined by those who participated in one or more endurance events (long course) in the year or as well as those who are (younger, low BMI cohort) MD and classification of “dense breasts” was heterogeneous and extremely dense as noted by the BIRADS code; (heterogeneously or extremely dense vs scattered fibroglandular densities). Data is collected as odds ratio (OR’s) and 95% confidence intervals included in research outcomes.

Although breast density is a well-established and prevalent breast cancer risk factor, it’s biological connection is not (yet) clearly understood.  More research is needed to support the population associated risk proportion in athletic pre-menopausal women.  The data gathered from this study reviews a cohort of women undergoing imaging ultrasound scans of pre-menopausal women with dense breasts. Anecdotally, 50 years ago one never saw a 35-year-old with breast cancer. Twenty years ago, it was common to see women in their 20s with cancer. Environmental factors and toxic substance carcinogenic effect may be a byproduct of the research outcome. 



Non-invasive Imaging options

1) Diagnostic Ultrasound meets the scanning requirements and is performed in the office setting accurately and rapidly due to the high resolution and low cost of today’s sonographic equipment.  Furthermore, advances in the computerization of the imaging, blood flow, and tumor measures of exact volume and vessel density are now less operator dependent- adding ease of use for this or any clinical research requiring the use of ultrasound technology. This provides a reliable and repeatable diagnosis, and a means to follow the individual’s unique pattern of cancer development, progress, and response to treatment. 

Recent technological advances also make these procedures available to much broader clinical application, without requiring years of very unique training and clinical experience, for example, with diagnoses of cystic versus solid lesions. Accuracy in assessing breast [1] tumors and metastatic foci has been documented. It must be emphasized that the beginner will find many confusing artifacts and findings should be confirmed with all pertinent imaging modalities.

2) 3D Doppler Ultrasound with Dynamic Contrast Enhanced MRI are the gold standards by which cancers are initially diagnosed or confirmed and serially followed after treatment. The percentage of malignant vessels can be quantified and re-evaluated in the identical tumor volume as serial follow ups to the standard treatments using radiation, surgery, hormones, chemotherapy, cryotherapy, watchful waiting and the non-standard regenerative treatments: ablation using focal laser, focal ultrasound, photodynamic, radiofrequency and microwave technologies. Since vessel mapping is possible, embolic treatments may be considered.

3) 3D Sonography can demonstrate the tumor volume and marginal capsule of locally affected lymph nodes more accurately than the MRI since the resolution is 100 microns at 18 MHz. The exam takes about 10 minutes, and the probes are automated meaning that this is less operator dependent than other sonographic procedures. Vessel density index (VI) imaging is performed on the data set at an independent workstation and comparison made with prior exams if available.

4) 3D Power Doppler indices vary according to the tumor stage, the histologic grade, capsular disruption, and lymph node metastases. Histologic grade has been studied with this technology and the following approximation has proven useful in prostate tumor staging. This quantitative measure of neovascularity was initially applied to prostate cancer. [2] While it does not exactly correlate with histologic Gleason grading since this is a current functional measure while the microscopy is purely anatomical and may not represent current aggressive potential. It’s predictive value of aggression could be studied in the context of breast and other cancers [3,4]

Medical imaging can map the arteries, veins and nerves providing preoperative landmarks reducing postoperative bleeding and avoiding nerve damage. Tumors of low aggressive potential may be treated medically and followed by interval scans or locally reduced by radiation or laser ablation. Biopsies of certain abnormalities may be averted or postponed. (FIG 1)

Fig. 1 -  Left black and white coronal ultrasound shows irregular “donut” periphery corresponding to desmoplastic tissue while the right colored elastography demonstrates the fibrotic elements creating the “crater” interior 



Part 2: TRACKING BREAST CANCERS AND TUMORS

High tumor vessel density correlates with greater aggression.  Axillary and mediastinal imaging can document lymphadenopathy. Abdominal scans simultaneously performed may detect ascites and metastases to the liver, periaortic nodes and pelvic organs. Response to neoadjuvant chemotherapy may be assessed MRI, CT, mammography, PET/CT and ultrasound. The new technology of ultrasound elastography, assessing tumor stiffness, predicts response to treatment accurately and may indicate better therapeutic strategies on a timelier basis. [5] Residual cancer burden scoring could provide better treatment options since the treatment response for evaluation of neoadjuvant chemotherapy needs a more comprehensive and authoritative standard than is currently available. 


Lymph Node Disease 

Lymph node assessment is possible at the same time. Under sonographic guidance, biopsies may be obtained. Sonographic criteria for malignancy are published elsewhere. Image guidance of enlarged node can distinguish between active tumor and necrotic areas diminishing necessity of repeated aspirations for indeterminate findings. (Fig 2) Pathologic assessment of a large postoperative specimen may be facilitated by high frequency scanning to re-localize the suspect region for targeted study that has been removed from its previous anatomic position. [6] Elastography is useful in targeting sub-centimeter foci in large nodal masses

Fig. 2 - Vessel mapping preoperative


Part 3: IMAGE GUIDED BIOPSY AND TREATMENT

New computer programs use nanotechnology and cybernetic modalities for accurate image guided biopsy and treatment options. Lesions as small as 3 mm have been successfully imaged at frequencies above 14 MHz. Employing 3D sonography with Doppler, the physician manually targets the area of highest tumor neovascularity. This is critical since only part of a mass may be cancerous and missed on non targeted punch biopsies. The marriage with fusion of MRI with ultrasound permits image guided biopsies that spare the adjacent vascular channels. The same technology allows customized ultrasound or MRI guided biopsies to be performed under local anesthesia. Immediate cytologic confirmation of tumor cells permits the withdrawal of the biopsy needle and insertion of a LASER fiber or cryogenic probe immediately treating the proven tumor. MRI thermocoupled sensors prevent overheating of the adjacent nerves and sensitive tissues. Following ablation, the zone of destruction is confirmed with Doppler, contrast ultrasound or DCE-MRI. Inflammatory lesions that are deeply seated may be approached by robotic image guided subdermal injections or targeted biopsies if necessary. This outpatient procedure allows the patient to return to work immediately. RF thermoprobes with temperature auto cutoffs prevent thermal skin damage.[7] Similar user friendly and cost-effective modalities may replace other therapies in the near future. At the 2016 AMERICAN SOCIETY OF LASERS IN MEDICINE meeting in Boston, cutaneous melanoma with in-transit metastases was successively treated by laser technologies [8] MRI Fusion Biopsies with CT and/or ultrasound are routine adding further to the accuracy of image guided biopsies and focal treatment procedures. [9]

Advances in ultrasound elastography progressed from simple strain imaging to shear wave sonography to 3D coronal shear wave elastography where the plane of the image corresponds to the surgical field as the tumor is dissected in the most superficial plane. The tumor desmoplasia in the coronal plane creates a sawtooth irregular border with a central echo pattern simulating a “donut” and is termed the “crater” sign in this increasingly popular imaging paradigm. Elastography is used worldwide primarily in the diagnostic workup of breast, thyroid and prostate tumors and has reduced the number of biopsies on false positive findings from mammography, b-mode ultrasound and MRI.[10]




Fig. 3 - Mixed solid/necrotic axillary lymph node-vessel density allows targeting of active disease







References

1. Bard R. Vascular imaging of cancer in the dense breast. 60th Journees Francaises de Radiologie 2012, Paris

2. https://www.breastcancer.org/symptoms/understand_bc/statistics 

3. Cruwys, Cheryl, and JoAnn Pushkin. “Breast density and impacts on health.” ecancermedicalscience 11 (2017).

4. Nazari, Shayan Shaghayeq, and Pinku Mukherjee. “An overview of mammographic density and its association with breast cancer.” Breast cancer 25.3 (2018): 259-267.

5. Boyd, Norman F., et al. “Mammographic density: a heritable risk factor for breast cancer.” Cancer epidemiology. Humana Press, 2009. 343-360.

6. Burton, Anya, et al. “Mammographic density and ageing: A collaborative pooled analysis of cross-sectional data from 22 countries worldwide.” PLoS medicine 14.6 (2017): e1002335.

7. Azam, Shadi, et al. “Determinants of mammographic density change.” JNCI Cancer Spectrum 3.1 (2019): pkz004.

8. Boyd, Norman F., et al. “Body size, mammographic density, and breast cancer risk.” Cancer Epidemiology and Prevention Biomarkers 15.11 (2006): 2086-2092.

9. Bard R. Image guided cancer treatment. Advances in Medical and Surgical Dermatology, 15th Annual Mt Sinai Winter Symposium New York 2015.

10. Merce L, Alcazar J, Lopez C et al. Clinical usefulness of 3-dimensional  sonography and power Doppler angiography for  diagnosis of endometrial carcinoma. J Ultrasound Med 2007; 26:1279-1289.


Disclaimer & Copyright Notice: The materials provided on this website/web-based article are copyrighted 2021 and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and Bard Diagnostic Research & Educational Programs). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.


Tuesday, September 28, 2021

Dense Breast Research: Code name IRON-WOMAN

Research overview: MAMMOGRAPHIC DENSITY, PHYSICAL ACTIVITY AND BREAST CANCER

Written by: Dr. Noelle Cutter / Sept. 12, 2021
Edited by: the publishing team @ NYCRANEWS.com

Mammography, as the primary screening modality, has facilitated a substantial decrease in breast cancer-related mortality in the general population. However, the sensitivity of mammography for breast cancer detection is decreased in women with higher breast densities, which is an independent risk factor for breast cancer. With increasing public awareness of the implications of a high breast density, there is an increasing demand for supplemental screening in these patients. Yet, improvements in breast cancer detection with supplemental screening methods come at the expense of increased false-positives, recall rates, patient anxiety, and costs. Therefore, breast cancer screening practice must change from a general one-size-fits-all approach to a more personalized, risk-based one that is tailored to the individual woman's risk, personal beliefs, and preferences, while accounting for cost, potential harm, and benefits.


FACTOIDS & FIGURES- The Inspiration behind our research initiative [1]

▪ Breast cancer is the second most common cancer among women in the United States and about 1 in 8 U.S. women (about 13%) will develop invasive breast cancer over the course of her lifetime.

▪ In 2021, it is estimated that over 280,000 new cases of invasive breast cancer will be diagnosed in women in the U.S., 

▪ Over  40,000 women in the U.S. are expected to die in 2021 from breast cancer. Unfortunately, death rates have been steady in women under 50 since 2007, despite advancements in treatment options.

▪ For women in the U.S., breast cancer death rates are higher than those for any other cancer, besides lung cancer.

▪ As of January 2021, there are more than 3.8 million women with a history of breast cancer in the U.S. This includes women currently being treated and women who have finished treatment.

▪ Breast cancer is the most commonly diagnosed cancer among American women. In 2021, it's estimated that about 30% of newly diagnosed cancers in women will be breast cancers.

▪ Breast cancer became the most common cancer globally as of 2021, accounting for 12% of all new annual cancer cases worldwide, according to the World Health Organization.

▪ A woman’s risk of breast cancer nearly doubles if she has a first-degree relative (mother, sister, daughter) who has been diagnosed with breast cancer.

Click for full lecture with Dr. N. Cutter & Dr. L. Bard
▪ About 5-10% of breast cancers can be linked to known gene mutations inherited from one’s mother or father. Mutations in the BRCA1 and BRCA2genes are the most common. On average, women with a BRCA1 mutation have up to a 72% lifetime risk of developing breast cancer. For women with a BRCA2 mutation, the risk is 69%. Breast cancer that is positive for the BRCA1 or BRCA2 mutations tends to develop more often in younger women. 

▪ About 85% of breast cancers occur in women who have no family history of breast cancer. 

The most significant risk factors for breast cancer are sex (being a woman) and age.  But recent research is beginning to clarify additional risk factors associate with BC


PHYSICAL ACTIVITY 
Physical activity is considered a significant modifiable factor in breast cancer risk, and since exercise reduces fatty tissue and BMI, it has been thought to increase breast density. However, studies into the relationship between physical activity and breast density have been inconclusive. Other factors such as alteration in metabolism of endogenous hormones, are suggested to influence mammographic density (MD) as well. Therefore, it is evident that the links between physical activity and breast cancer risk need to be clarified.

BREAST TISSUE DENSITY 
Breast density levels refer to the appearance of the breast tissue on a mammogram.  Breast density is part of the supportive or connective tissue that makes up the breast tissue. As you can see in this image, breast tissue is white to gray and transparent against a dark background.  Denser breast tissue appears more white whereas fatty/non-dense tissue appears grapy and transparent. 

Levels of density are described using a results reporting system called Breast Imaging Reporting and Data System (BI-RADS). The levels of density are often recorded in your mammogram report using letters. The levels of density are:

A: Almost entirely fatty indicates that the breasts are almost entirely composed of fat. About 1 in 10 women has this result.

B: Scattered areas of fibroglandular density indicates there are some scattered areas of density, but the majority of the breast tissue is non-dense. About 4 in 10 women have this result.

C: Heterogeneously dense indicates that there are some areas of non-dense tissue, but that the majority of the breast tissue is dense. About 4 in 10 women have this result.

D: Extremely dense indicates that nearly all of the breast tissue is dense. About 1 in 10 women has this result.

In general, women with breasts that are classified as heterogeneously dense or extremely dense are considered to have dense breasts. Almost half of women undergoing mammograms have dense breasts.


FATTY TISSUE vs. DENSE TISSUE 
A close up here shows the difference in imaging for a breast tumor on non-dense vs dense breast tissue using a mammogram. Breast density has been widely considered a strong risk factor for breast cancer, with statistics suggesting as much as a six times higher likelihood of the disease in breasts, compared with those with a less dense breast tissue.  Not only does dense breast tissue make it harder for a mammogram to pick up small tumors, but dense breasts themselves have been associated with a higher chance of cellular abnormality.



 

WHY IT MATTERS? 
Women who have dense breast tissue have a higher risk of breast cancer compared to women with less dense breast tissue. It’s unclear at this time why dense breast tissue is linked to a higher lifetime risk of breast cancer. Understanding that link is extremely important.

Dense breast tissue also makes it harder for radiologists to see cancer. On mammograms, dense breast tissue looks white. Breast masses or tumors also look white, so the dense tissue can hide tumors. But fatty tissue looks almost black. On a black background it’s easier to see a tumor that looks white. So, mammograms can be less accurate in women with dense breasts.

One of the challenges in promoting the widespread utility of breast cancer risk prediction models has been the assertion that most women with a diagnosis of breast cancer have no established clinical breast cancer risk factors or are not considered to be high risk. [1][2] Although it is impossible to determine the cause of breast cancer in any individual case [3] easily assessed risk factors that explain a substantial proportion of incident breast cancers can be used to stratify breast cancer risk for targeted screening [4] and primary prevention [5] and improve public health interventions to reduce breast cancer risk.

Recent research has suggested that for women with dense breasts, a screening strategy that also takes into account a woman’s risk factors and protective factors may be the best predictor of whether a woman will develop breast cancer after a normal mammogram and before her next scheduled mammogram.


MAMMOGRAPHIC DENSITY 
Breasts contain glandular, connective, and fat tissue. Breast density is a term that describes the relative amount of these different types of breast tissue as seen on a mammogram. Dense breasts have relatively high amounts of glandular tissue and fibrous connective tissue and relatively low amounts of fatty breast tissue.


HOW COMMON ARE DENSE BREASTS? 
Nearly half of all women age 40 and older who get mammograms are found to have dense breasts. Breast density is often inherited, but other factors can influence it. Factors associated with lower breast density include increasing age, having children, and using tamoxifen. Factors associated with higher breast density include using postmenopausal hormone replacement therapy and having a low body mass index.

Women with dense breasts have a higher risk of breast cancer than women with fatty breasts, and the risk increases with increasing breast density. This increased risk is separate from the effect of dense breasts on the ability to read a mammogram. MD one of the strongest risk factors. And because individuals with denser breasts tend to develop more serious types of breast cancer, understanding the connection is important.


ATHLETES 
A common question that invariably comes up when discussing breast density relates to breast density in athletes. As an athlete myself who has dense breasts, I was struck by the number of individuals in my athletic community who also have dense breasts.  A shocking trend was seen in the overwhelming amount of young women with dense breasts who subsequently had received false negative mammogram reports.

What we do know is that your breast tissue tends to become less dense as you age, though some women may have dense breast tissue at any age. Women with less body fat are more likely to have more dense breast tissue compared with women who are obese. From observation (thus far), athletic women are also more likely to have dense breast tissue. One of the main goals of our study is to really try to understand the biological connection of breast density in athletes as well as run a retrospective study on how common this trend is.


RESEARCH OBJECTIVES 
It's not clear why some women have a lot of dense breast tissue and others do not. You may be more likely to have dense breasts if you:

▪ ARE YOUNGER; your breast tissue tends to become less dense as you age, though some women may have dense breast tissue at any age.

▪  HAVE LOWER BMI (body mass index); women with less body fat are more likely to have more dense breast tissue compared with women who are obese.

Breast density is shown to be associated with breast cancer risk in women aged 40 to 65 years, but there is limited evidence thus far of its association with risk of breast cancer among women 18+. Furthermore, a high proportion of women with low BMI present with dense breasts, making them likely candidates to receive false negative readings on a mammogram.  We aimed to estimate the proportion of breast cancers attributable to breast cancer risk factors commonly documented in clinical practice and used in breast cancer risk prediction models, including BI-RADS breast density and ultrasounds to confirm mammography readings. Our data will be collected from a cohort of women undergoing ultrasound density scans at the Bard Cancer Center (NYC).

Although breast density is a well-established, strong, and prevalent breast cancer risk factor it’s biological connection is not clearly understood.  More research is needed to support the population associated risk proportion in athletic pre-menoposal women. Our data will start with a cohort of women undergoing imaging ultrasounds at the Bard Cancer Diagnostic Center.  Our population will include pre-menoposal women with dense breasts.


METHODS 
Endurance athletes are defined those who participated in one or more endurance events (long course) in the year or as well as those who are (younger, low BMI cohort). MD and classification of “dense breasts” was heterogeneous and extremely dense as noted by the BI_RADS code; (heterogeneously or extremely dense vs scattered fibroglandular densities). Data will be collected as odds ratio (OR’s) and 95% confidence intervals included in our outcomes

Cross-sectional Analysis

1000+ pre-menopausal women aged 18+

Collect information on height, weight, BMI and history of disease

Physical activity assessment

MD measurement performed by radiologist and confirmed by ultrasound

Logistic regression used to estimate the association of MD within participation in physical activity


JAMA STUDY: 
A recent report in Journal of the American Medical Association found that first-degree family history of breast cancer dense breasts were associated with an increased population associated risk proportion of breast cancer. Among premenopausal women, the largest individual population associated risk proportion was for breast density, with 28.9% (95% CI, 25.3%-32.5%) of breast cancers potentially removed by reducing breast density from BI-RADS heterogeneously or extremely dense breasts to scattered fibroglandular densities. The population associated risk proportion for breast density increased to 65.5% (95% CI, 60.4%-70.6%) if all premenopausal women reduced their breast density to the lowest category of almost entirely fat tissue. 

SUMMARY/ WRAP-UP 
Given that greater breast density as categorized by the BI-RADS remains a factor associated with breast cancer for all ages of women, information about breast density together with life expectancy may benefit clinical decision-making regarding screening. In March 2019, the US Food and Drug Administration recommended changes to the Mammography Quality Standards Act to make it mandatory to report breast density information to both patients and their physicians. However, how women and their physicians should use this information to inform screening recommendations is unclear. Very dense breasts may increase the risk that cancer won't be detected on a mammogram.

What is clear is that additional research is needed to elucidate the mechanisms underlying the observed associations between breast density and risk of breast cancer. As newer and more advanced breast density assessment techniques are developed, evaluation of the diffusion of such innovations with an aim of developing individualized screening strategies will be important, particularly among athletic women, for whom dense breast are more likely seen.



EPILOGUE 

Dr. Noelle Cutter is a professor of biology, ironman finisher, and advocate for dense breast screening.  United with an expanding research team dedicated to collecting data on women with dense breasts and screening options for these patients, her initiative aims to investigate and gather conclusive information about dense breasts in specific groups- including age, body mass index, and amount of physical activity and the underlying diagnostics of breast cancer tumors. This research program is under a partnership with Molloy College and Dr. Robert Bard, expert diagnostic cancer imaging specialist in NYC and other colleagues from the NY Cancer Resource Alliance. 

With your support, we are able to implement this screening program for women's health as well as help fund this clinical research.  Our work will advance technology, change legislation and most importantly save lives through awareness.



On July 27-29, Bard Diagnostic Imaging is offering a comprehensive DENSE BREAST SCREENING DAY, employing an array of imaging advancements dedicated to the visibility of dense breast tissue and cancer early detection. This special program is dedicated to supporting dense breasted patients by first identifying one's actual breast density (through a density assessment scan) to establish a base line for the full diagnostic study (est. 15-20 minutes per patient).

Dr. Bard has formulated a comprehensive early detection program specific for dense breasted women. This includes the latest technologies in breast ultrasound, scanning. "We need screening technology for dense breasts because the mammography misses too many cancers in dense breast. So patients are happy to know that this technology is here. If there is a problem, you focus in on it in three dimensions, you find out where it is, and then you, uh, address it with a biopsy or an MRI or a specialized ultrasound." For decades. The ultrasound has advanced greatly in accuracy and reliability to scan quickly. In real time, patients are attracted to its safety aspect, eliminating concerns for radiation and other physical after effects.




REFERENCES

1) https://www.breastcancer.org/symptoms/understand_bc/statistics 

2) Cruwys, Cheryl, and JoAnn Pushkin. “Breast density and impacts on health.” ecancermedicalscience 11 (2017).

3) Nazari, Shayan Shaghayeq, and Pinku Mukherjee. “An overview of mammographic density and its association with breast cancer.” Breast cancer 25.3 (2018): 259-267.

4) Boyd, Norman F., et al. “Mammographic density: a heritable risk factor for breast cancer.” Cancer epidemiology. Humana Press, 2009. 343-360.

5) Burton, Anya, et al. “Mammographic density and ageing: A collaborative pooled analysis of cross-sectional data from 22 countries worldwide.” PLoS medicine 14.6 (2017): e1002335.

6) Azam, Shadi, et al. “Determinants of mammographic density change.” JNCI Cancer Spectrum 3.1 (2019): pkz004.

7) Boyd, Norman F., et al. “Body size, mammographic density, and breast cancer risk.” Cancer Epidemiology and Prevention Biomarkers 15.11 (2006): 2086-2092.

8) Masala, Giovanna, et al. “Can Dietary and Physical Activity Modifications Reduce Breast Density in Postmenopausal Women? The DAMA Study, a Randomized Intervention Trial in Italy.” Cancer Epidemiology and Prevention Biomarkers 28.1 (2019): 41-50.

9) Wyshak, Grace, and Rose E. Frisch. “Breast cancer among former college athletes compared to non-athletes: a 15-year follow-up.” British journal of cancer 82.3 (2000): 726.

10) McCormack  VA, dos Santos Silva  I.  Breast density and parenchymal patterns as markers of breast cancer risk: a meta-analysis.   Cancer Epidemiol Biomarkers Prev. 2006;15(6):1159-1169.


Disclaimer & Copyright Notice: The materials provided on this website/web-based article are copyrighted 2021 and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and Bard Diagnostic Research & Educational Programs). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.


                                    



Friday, August 20, 2021

A NEED TO STANDARDIZE SCREENING WITH DENSE BREAST SCANNING

 

RUNNING THE TORCH OF A DENSE BREAST CANCER CHAMPION
Dr. Noelle Cutter drives the spirit of Dr. Nancy Cappello's mission for early cancer detection for women with dense breasts alongside Dr. Robert Bard's dense breast screening pilot program (8/27-29) - and the global pursuit to expand current screening standards.

What Does It Mean to Have Dense Breasts?


A mammogram shows how dense your breasts are. When you get the results of your mammogram, you may also be told if your breasts have low or high density. Women with dense breasts have a higher risk of getting breast cancer.


















PARTS OF THE BREAST
A woman’s breast has three kinds of tissue: FIBROUS TISSUE holds the breast tissue in place.  GLANDULAR TISSUE is the part of the breast that makes milk, called the lobes, and the tubes that carry milk to the nipple, called ducts. Together, fibrous and glandular tissue are called fibroglandular tissue.  FATTY TISSUE fills the space between the fibrous tissue, lobes, and ducts. It gives the breasts their size and shape.

BREAST CANCER RISK: Women with dense breasts have a higher chance of getting breast cancer. The more dense your breasts are, the higher your risk. Scientists don’t know for sure why this is true. Breast cancer patients who have dense breasts are not more likely to die from breast cancer than patients with non-dense (fatty) breasts.



7/8/2021- A wave of recognized medical sites, journals and reports  are now indicating that dense breast tissue increases the risk of developing breast cancer and often masks a tumor from being seen on the mammogram since dense tissue is white and cancerous tissue is also white. Mammograms are the standard screening test for breast cancer, however, in the 21st Century, ultrasound non invasive imaging is the preferred exam for dense “lumpy” mammary disease.   

The 1st World Conference of Breast Ultrasound in Philadelphia (1979) recognized ultrasound superiority in dense breast diagnostics but the density level was never quantified until recently. Mammography assessment of breast density is graded into four categories. Mammographers readily admit that these levels are subjective at best and technical factors such as mammary tissue compression and x-ray voltage/amperage dramatically influence the darkness or whiteness of the image.



URGENCY IN THE EVOLUTION OF TECHNOLOGY & IMAGING STRATEGIES FOR DENSE BREASTS

Written by: Dr. Robert L. Bard

Decades since the advent of breast scanning technology, innovations in non-invasive diagnostic imaging provide new options in the field of early detection. These technologies directly align with breast density screening (and are part of the Bard Breast Density Diagnostic Program) include:

• Doppler blood flow
• Contrast enhanced ultrasound vascularity 
• 3D Vessel Density Histogram 
• 4D Volumetric Density Histogram
• Strain and shear wave tissue Elastography 
• 3T MRI 
• Optical Computed Tomography (OCT) for nipple lesions
• Reflectance Confocal Microscopy (RCM)  for dermal invasion
• Hybrid Mammo Imaging Fusion
 Thermo-sensor
 Trans Illumination
 Near Infrared Specroscopy

Hybrid imaging refers to combining diagnostic modalities to assess disease and monitor therapy. A useful combination of options is the tumor vessel flow density to assess aggression and treatment progress. Similarly, tissue elastography is useful for border detection of malignant masses.


FOR COMPLETE DETAILS ON THIS PROGRAM, VISIT: http://breastcancernyc.com/

Monday, July 26, 2021

TUMOR DETECTION FOR DENSE BREASTS

BREAST CANCER DECODED  By: Robert L. Bard, MD

  

CONCEPT AND APPROACH

Drastic changes in the incidence, diagnosis and treatment of breast cancer and benign breast disease highlight a singular need for an up to date source on the early detection and proper therapy of breast tumors.  The age of occurrence of breast cancer, formerly only a problem of older women, is now at a median age of 45 years.  This means that women in their twenties are developing breast cancer.  Although risk factors have been identified, the jeopardy to life is unchanged.  The increasing use of estrogen for osteoporosis and other female disorders may elevate the risk of breast cancer.  One out of every eight women will develop breast cancer.  Fortunately, the vast majority of tumors in younger women are benign and can be diagnosed by simple, safe non surgical tests.  Jewish women, prone to breast cancer, are further plagued by the concomitant presence of fibrocystic breasts that are lumpy and mask a growing breast cancer.


The incidence of miss by mammography increases markedly in younger patients and those with "mastitis" or "cystic" breasts.  A paper from the University of Indiana Medical Center on the mammographic diagnosis of fibroadenomas (benign tumor of young women) demonstrated that in 35 surgically proven biopsies, the mammogram missed every mass. A non x ray exam, called the sonogram, was able to diagnose every tumor in this study. Another non-x ray test, called Doppler ultrasound, according to DIAGNOSTIC IMAGING (1988) and CLINICAL RADIOLOGY (1990) may detect breast tumors not seen by all other tests. Light scanning is another procedure that uses computers and fiberoptics to visualize tumors.

The latest text book on Breast Disease, BREAST ULTRASOUND by Thomas Stavros (Lippincott, 2002) mentioned that most abnormalities of the breast may be better characterized or even detected only by diagnostic ultrasound procedures. JAMA (May 1993) noted mammography readings were highly variable with many false positives. Moreover, one expert missed 67% of cancers on high quality mammograms. Indeed, top mammographers disagreed clinically in 1/3 of readings.

 Since cancers may lie dormant for up to ten years and that mammography is less accurate in younger women, one realizes that sonography becomes necessary for a complete workup in the detection of invasive. Mayo Clinic computer program shows sonograms capable of 99% accuracy. The latest malpractice newsletters warn physicians that they are liable if they miss a breast cancer because they have not performed a sonogram. In fact, the PIAA Data Sharing Report shows that the patient found the tumor in 69% of cases, mammography missed or was equivocal in 49% and the median age of breast cancer was 43 years of age. False negatives were highest in the under age 40 group comprising 40% of claims.

 

BREAST IMPLANTS                

Every year over 150,000 women have breast implants. Recent press has pointed to the problem of breast cancer development in the augmented breast and the inability of mammography to see it.

Mammography has also long been used as the primary diagnostic imaging study for complications of breast augmentation in the over one million women who currently have breast implants. However, lack of accuracy of both mammographic information and clinical interpretation have necessitated the application of the non x ray imaging modalities of light scanning, sonography and duplex Doppler ultrasound.

Every plastic surgeon has received a radiologist's mammogram report on a patient in whom a long standing implant has been removed for various complications that referred to the ovoid shaped density as a "prosthesis in position."  Radiographically, the hard capsule that forms after a year cannot be differentiated from certain implant devices. Also, a leakage of silicone gel that is restricted to the fibrous capsule is not separately distinguishable. Thus, x rays are inadequate for the diagnosis of implant rupture except where the silicone has extruded physically through the capsule. Even then, the routine views may not demonstrate leakage that is close to the surface of the capsule so that it will only be identified by a tangential x ray beam. An irregular outline of an implant may be positional, caused by adjacent breast pathology, resultant of fibrous septation or actually due to implant rupture.

A sonogram identifies an implant much the same as a cyst. Thus the size, shape, position, peripheral envelope, wall contour and internal echo pattern are readily demonstrable. Rupture of an implant, whether from structural failure, interoperative damage, penetrating trauma or blunt trauma such as closed capsulotomy, is quickly and accurately diagnosed by routine high frequency sonography.

Sonography is also important in breast cancer diagnosis since the implant masks most of the breast from the x ray. Dr. Levine, in the 1990 article: DEFINITIVE DIAGNOSIS OF BREAST IMPLANT RUPTURE BY ULTRASONOGRAPHY in "Plastic and Reconstructive Surgery" states that sonography is the best imaging modality for the augmented breast.

Perhaps more interesting are the roles of light scanning and duplex Doppler imaging in the diagnosis of the cause of the implant rupture. Spontaneous failure of the envelope will be accompanied by fluid extravasation. If recent and localized, light scanning and Doppler flows will be unremarkable. A long standing leakage may become secondarily infected, thus producing unilateral light absorption. Similarly, trauma, intraoperative or external, may be associated with bleeding which will also absorb light rays. Thus, a normal light scan exam in transillumination suggests the probability of structure failure of the implant. Duplex Doppler may shows linear fluid filled structures to be adjacent arteries or veins. Additionally, this procedure may detect cancers adjacent to the implant.

 The treatment of breast disease has also changed from the days of deforming radical mastectomies.  Simple removal of the tumor followed by mastectomy, chemotherapy and radiation therapy are now available.  Post mastectomy reconstructive surgery will often restore a woman to her former natural shape.  In England and Australia, where breast ultrasound and Doppler analysis are routinely used, exploratory surgery has decreased 90%.  The American Cancer Society stresses self examination and mammography.  Unfortunately, the survival rate of breast cancer has not changed in the past 25 years.  Clearly, other diagnostic exams are needed, since the cure rate is related to the early detection of the disease. Alarmingly, despite many years of ongoing, improved and massive breast cancer screening, the US National Center for Health Statistics now sates that the incidence of number of cases of this disease is actually increasing.

 Many women are overwhelmed with the variety of medical tests and their safety. Recent articles in the NY Times stated that the female patient is psychologically ill equipped to deal with the emotional trauma of breast cancer at the time of diagnosis. These reports suggest that women be well informed prior to the discovery of a tumor, so that they may make a better informed decision.  The book addresses the specific type of exam for both early detection of breast disease as well as the optimal test for specific disorders for each individual woman in an orderly, sequential and safe format.  The pro's and con's of treatment protocols are also formatted.  The author, a radiologist specializing in new methods of breast imaging, has been lecturing for the Ultrasonic Institute on new methods of breast cancer detection since 1973 at medical centers around the nation and at international conferences and mentions in this book all types of exams and therapies.  The reader chooses for herself what modality may be most suitable.  Methods used in Europe, for example, find acceptance in American medicine twenty or thirty years later.  Some medical regimens may be generally unsuitable for patients, yet may be ideal or the only possibility for an individual woman.  Diagrams of the various exams are available for better appreciation of the visually oriented test.  As a ready reference format, each chapter is preceded by a one page summary for quick review.  The overall aim of the work is to be a health "bible" for breast disorders for the 1990's woman.  

It is obvious that too few women are getting the message about the importance of early breast cancer detection since they fear that it will be too late or the therapy will be too deforming.  The purpose of the book is to show that CHANCES ARE ITS BENIGN, AND, PROPER TREATMENT CAN SAVE YOUR LIFE AND NOT DISFIGURE.  The work reaches out to the reader to reassure her with dramatic evidence that taking control of her breasts' health in a planned, stepwise manner can mean the difference between the words:  "The scan shows it's a cyst.  Don't worry" and the chilling sentence, "we could have helped you if you come in earlier."  Women walk out of my office, knowing that their lump is benign and that their fears are nothing, looking ten years younger.  

Women with cancer can be helped because of the simple techniques used when tumors are small.  Even men develop breast cancer at a rate approximately 1% that of women. Most women do need to know that CHANCES ARE ITS BENIGN.  Since the age range of breast cancer is now from the teens to the hundred's, women of all ages need to become actively involved in managing their health just as they do their finances. Since all women are at risk of breast cancer, all families must know the facts and the choices involved. Jewish women, successful women, women on hormones, women with breast implants and the growing number of health conscious people of all ages will want to know thee available regimens so they have the data necessary to knowledgeably take charge of the their own lives.

 

REVIEW OF CURRENT MEDICAL LITERATURE 

Fleisher's DIAGNOSTIC SONOGRAPHY (Saunders 1989) states that a sonogram is the best method for diagnosing benign disorders and that a mammogram is the better tool for diagnosing malignant diseases. He quotes the sensitivity of sonograms in cancer detection at 69% as compared to the mammographic detection rate at 74%. The author's own series using a hand held real time unit (same as Dr. Bard's) shows an accuracy in detecting palpable lesions of 85% for sonograms and 70% for mammograms. Both modalities yield a rate of 89% and he recommends both tests be used in combination.

Hagen-Ansert's TEXTBOOK OF DIAGNOSTIC ULTRASOUND (Mosby 1989) states sonogram is clinically useful in a) dense breasts  b) younger patients  c) uncertain mammographic findings  d) pregnant patients   e) implants  f) differentiation of cystic from solid in a known mass

Kopan's BREAST IMAGING (Lipincott 1989) states that sonography should not be used for cancer screening. However, he quotes studies by Sickle's, Cole, and Egan showing respectively that sonogram detects cancers at the following rates: 58%, 78% and 79% in the general population 

Britton's article in CLINICAL RADIOLOGY (1990) demonstrates duplex doppler having a sensitivity of 91% and specificity of 89%.

Levin's paper in PLASTIC AND RECONSTRUCTIVE SURGERY (1991) mentions that mammography is unreliable in the post augmented breast and that ultrasonography is the test of choice for evaluation of breast prostheses.

Dixon's paper in BRITISH J SURGERY (1992) showed 78% sensitivity and 100% specificity for carcinoma using duplex Doppler.

Adler’s abstract in ULTRASOUND MED BIOL (1990) has 82% detection rate of malignant neovascularity with duplex Doppler. 

Scatarige's note in THORACIC RADIOLOGY (1989) shows high accuracy of staging internal mammary lymphadenopathy.

Jones review in CLINICAL ONCOLOGY (1990) had sonograms picking up axillary nodes missed by other methods in 27% of cases.

Levin's paper in PLASTIC AND RECONSTRUCTIVE SURGERY (1991) mentions that mammography is unreliable in the post augmented breast and that ultrasonography is the test of choice for evaluation of breast prostheses.

Parker's lecture at the NYU BREAST CANCER UPDATE (1993) showed sonography's ability to detect unsuspected cancers as small as 0.4 cm and determine whether the associated lymphadenopathy was malignant or benign. Mendellson's 1992 talk at DOWNSTATE MEDICAL CONFERENCE showed sonograms to be able to discover occult lesions.

Barth's 1993 study showing sonograms detected more than twice as much multicentric breast cancer than mammography.

Stavro's 1997 paper shows accuracy in detecting benign disease solely by ultrasound at 99.7 %.

Bard's paper in 1993 NY STATE JOURNAL OF MEDICINE revealing mammographic misses in breast implant imaging.

Bard's 1994 lecture at the MAYO CLINIC highlighted the accuracy of multimodality imaging.

Bard's 1996 FEMALE PATIENT paper showed 99% accuracy in benign disease diagnosis                           

 

CONCLUSION

As breast cancer strikes younger women due to lowering of the median age of occurrence, screening procedures become imperative.

Although mammography is the only generally accepted screening modality, it is clearly of limited use in younger patients or those with fibrocystic breasts.  The inaccuracy of sonograms is true if one considers the total population to be screened will predominate in older age groups. Kopan's, in his textbook, admits that he chooses to do sonograms on women under 28 because of anecdotal evidence that it works best. Dr. Bard's suggestion is that sonograms be the screening procedure of choice in younger women and those with fibrocystic breasts. Mammography should remain the gold standard in women over 40 or those with fatty breasts of any age. The combination of light scanning, Doppler ultrasound and standard sonograms of the breast often mean the difference between delayed diagnosis and immediate surgery. Multimodality imaging, the emphasis of this book, offers the patient the difference between weeks of worry for the mammogram to be repeated for "interval change" or for an immediate answer that the problem is benign.

 

 COMPETITION

Aside from a few books on cancer and women's diseases, there are no non-medical books on the spectrum of new tests and therapies for breast disease.  Given the epidemic proportions of breast cancer, the time is right for a new and comprehensive manual for today's concerned and aware women.

Books on personal health include THE DOCTOR BOOK, by Wesley Smith (Price Stern Sloan, L.A. 1987) which has one paragraph on breast exam by a physician and one paragraph on mammography. 

 

The NY TIMES GUIDE TO PERSONAL HEALTH by Jane Brody (Avon, 1982) has 7 pages on breast cancer with 2 paragraphs on diagnostic tests. 

HORMONES, by Lois Jovanovic, MD (Fawcett, 1987) includes 26 pages on breast disease, mentioning the fact that 90% of breast cancers are detected by women themselves, leaving the reader to wonder at the value of the "gold-standard" exams  of mammography and 2 pages on hormone therapy for breast cancer. 

 

CHOICES, by Marion Morra and Eve Potts (Avon 1987) also titled:  Realistic alternatives in cancer therapy, has one chapter on breast cancer, with 6 pages on mammography, one paragraph each on ultrasound, computed tomography, transillumination and thermography.  There are 16 pages on surgery and radiotherapy and 29 pages on post operative care.

 Lauersen's IT'S YOUR BODY (Berkely 1983) on p.418 states that sonograms will be effective in the future. Indeed, Dr. Lauersen routinely now performs sonography on his patients semiannually or more often in his private office.

Gross's WOMEN TALK ABOUT BREAST SURGERY (Harper 1991) has 2 pages mentioning a particular cancer was missed by mammogram and sonogram.

Levy's YOUR BREASTS (Noonday 1990) says one 1 page that benign cysts that are not palpable or show on x ray may be imaged with sonograms.

Thompson's EVERY WOMAN'S HEALTH (Prentice Hall 1990) says on one page that sonograms are useful in cyst detection.

Better Homes and Garden's FAMILY MEDICAL GUIDE (1989) mentions that sonogram is useful if mammography is unclear.

Harvard's YOUR GOOD HEALTH (HARVARD 1987) says on one page that sonogram is good for cyst detection.

Love's DR. SUSAN LOVE'S BREAST BOOK (ADDISON WESLEY 1990) has one half page each on sonogram and transillumination.

Hirshaut's BREAST CANCER: THE COMPLETE GUIDE (BANTAM 1992) has one half page each on sonogram and transillumination.

Many private practice radiologists are currently routinely screening women with cystic breasts or those under fifty with sonograms even though the American College of Radiology does not recognize this as a screening tool. However, there is no other acceptable alternative choice for the patient or better diagnostic tool for the physician other than the non specific MRI exam. Every finding (30% specificity) must be biopsied to be verified.

Wednesday, July 7, 2021

Ultrasound Significantly Reduces False Readings of DENSE BREASTS


Dr. Noelle Cutter drives the spirit of Dr. Nancy Cappello's mission for early cancer detection for women with dense breasts alongside Dr. Robert Bard's dense breast screening pilot program (8/27-29) - and the global pursuit to expand current screening standards.

What Does It Mean to Have Dense Breasts?


A mammogram shows how dense your breasts are. When you get the results of your mammogram, you may also be told if your breasts have low or high density. Women with dense breasts have a higher risk of getting breast cancer.


















PARTS OF THE BREAST
A woman’s breast has three kinds of tissue: FIBROUS TISSUE holds the breast tissue in place.  GLANDULAR TISSUE is the part of the breast that makes milk, called the lobes, and the tubes that carry milk to the nipple, called ducts. Together, fibrous and glandular tissue are called fibroglandular tissue.  FATTY TISSUE fills the space between the fibrous tissue, lobes, and ducts. It gives the breasts their size and shape.

BREAST CANCER RISK: Women with dense breasts have a higher chance of getting breast cancer. The more dense your breasts are, the higher your risk. Scientists don’t know for sure why this is true. Breast cancer patients who have dense breasts are not more likely to die from breast cancer than patients with non-dense (fatty) breasts.





TRIBUTE TO A GLOBAL CRUSADER
(Play Video-L) The NY Cancer Resource Alliance gives loving tribute to Dr. Nancy Cappello, co-founder of "Are You Dense" and chief crusader of the mission to bring change to the protocols and standards of Early Detection.   Her organization embarked in a global advocacy project to win legislation for dense breast scanning and to bring awareness to the need for better technologies and imaging interpretation. Today, her loving husband Joe continues her unending fight to save more lives through awareness, advocacy and her crusade for change.  (Also see below to read her full story in our ORG SPOTLIGHT section)


7/8/2021- A wave of recognized medical sites, journals and reports  are now indicating that dense breast tissue increases the risk of developing breast cancer and often masks a tumor from being seen on the mammogram since dense tissue is white and cancerous tissue is also white. Mammograms are the standard screening test for breast cancer, however, in the 21st Century, ultrasound non invasive imaging is the preferred exam for dense “lumpy” mammary disease.   

The 1st World Conference of Breast Ultrasound in Philadelphia (1979) recognized ultrasound superiority in dense breast diagnostics but the density level was never quantified until recently. Mammography assessment of breast density is graded into four categories. Mammographers readily admit that these levels are subjective at best and technical factors such as mammary tissue compression and x-ray voltage/amperage dramatically influence the darkness or whiteness of the image.



URGENCY IN THE EVOLUTION OF TECHNOLOGY & IMAGING STRATEGIES FOR DENSE BREASTS

Written by: Dr. Robert L. Bard

Decades since the advent of breast scanning technology, innovations in non-invasive diagnostic imaging provide new options in the field of early detection. These technologies directly align with breast density screening (and are part of the Bard Breast Density Diagnostic Program) include:

• Doppler blood flow
• Contrast enhanced ultrasound vascularity 
• 3D Vessel Density Histogram 
• 4D Volumetric Density Histogram
• Strain and shear wave tissue Elastography 
• 3 T MRI 
• Optical Computed Tomography (OCT) for nipple lesions
• Reflectance Confocal Microscopy (RCM)  for dermal invasion
• Hybrid Mammo Imaging Fusion
 Thermo-sensor
 Trans Illumination
 Near Infrared Specroscopy

Hybrid imaging refers to combining diagnostic modalities to assess disease and monitor therapy. A useful combination of options is the tumor vessel flow density to assess aggression and treatment progress. Similarly, tissue elastography is useful for border detection of malignant masses.









4D VOLUMETRIC DENSITY HISTOGRAM
This new variation of the 4D ultrasound imaging involves real time scanning of the entire breast and focusing of the greatest density tissue with 3D volumetric capture of the tissue. The computer searches the gray level of the images under study and provides a percentage (%) number of the whiteness of the volume under study.

This investigative process began in 2017 under a study of scar tissue and presented at the 2018 ASLMS meeting using elastography and volumetric sonogram density analysis. Breast cancers, like scar tissue, are dark while fibrocystic abnormal tissues is more white.

The clinical utility of 4D image acquisition is:

1. Automated electronics sampling of the tissue volume in real time

2. 200-300 images of a data set are generated in 5-15 seconds

3. The process is User-INDEPENDENT unlike standard 2D ultrasound which is highly user dependent

4. The data set for serial studies uses fixed parameters so that treatment efficacy may be rapidly compared 



INNOVATIONS REFLECTING A NEW IMAGING STRATEGY: MEET THE ABUS
The medical imaging and cancer communities are now taking strides toward the dedicated scanning of Dense Breasts.  As mammograms have been known to have difficulty seeing tumors through dense breast tissue, the demand to upgrade imaging standards is at its highest. Dense breasted patients carry the risk of a mis-read which may miss advanced cases of breast cancer.  

According to GE Healthcare, "Approximately 40% of women have dense breasts, one of the strongest common risk factors for developing breast cancer.  Having dense breasts increases a woman's chance of developing breast cancer by four to six times, and seventy-one percent of breast cancers are found in dense breasts.

Clinical evidence is growing about the effectiveness of ultrasound for finding small, node-negative, invasive cancers missed by mammography. In 2018, GE Healthcare launched the Invenia automated breast ultrasound (ABUS) 2.0 system in the U.S. This FDA Approveed ultrasound supplemental breast screening technology specifically designed for detecting cancer in dense breast tissue. When used in addition to mammography, Invenia ABUS can improve breast cancer detection by 55 percent over mammography alone. Invenia ABUS 2.0 supplemental imaging is designed for the screening environment, specifically for dense breast imaging. Invenia ABUS 2.0 diminishes operator variability and creates 3D ultrasound volumes to enable comprehensive analysis and comparison to multimodality exams. [1]

“We believe ABUS can help clinicians find significantly more cancers than mammography alone, especially in women with dense breasts,” said Luke Delaney, general manager of Automated Breast Ultrasound at GE Healthcare. “As breast ultrasound technology continues to advance, we are investing to continually improve image quality, workflow and patient comfort - all of which contribute to early detection and improved outcomes.” [1]


Dense Breasts: Answers to Commonly Asked Questions 

Q: How common are Dense Breasts?
A: Nearly half of all women age 40 and older who get mammograms are found to have dense breasts. Breast density is often inherited, but other factors can influence it. Factors associated with lower breast density include increasing age, having children, and using tamoxifen. Factors associated with higher breast density include using postmenopausal hormone replacement therapy and having a low body mass index.

Q: Are dense breasts a risk factor for breast cancer?
A: Yes, women with dense breasts have a higher risk of breast cancer than women with fatty breasts, and the risk increases with increasing breast density. This increased risk is separate from the effect (false negatives) of dense breasts on the ability to read a mammogram.



ORG SPOTLIGHT:

“ARE YOU DENSE”- FORGING A SMART, NEW PROTOCOL IN BREAST CANCER SCREENING

By: Joe Cappello of “Are You Dense” (areyoudense.org & areyoudenseadvocacy.org) | Edited by: Carmen R. DeWitt

Dr. Nancy Cappello's Story: "I have dense breast tissue – and women like me (2/3 of pre-menopausal and 1/4 of post menopausal) have less than a 48% chance of having breast cancer detected by a mammogram. In November 2003 I had my yearly mammogram and my "Happy Gram" report that I received stated that my mammogram was "NORMAL" and that there were "no significant findings." Six weeks later at my annual exam in January, my doctor felt a ridge in my right breast and sent me for another mammogram and an ultrasound. The mammogram revealed "nothing" yet the ultrasound detected a large 2.5 cm suspicious lesion, which was later confirmed to be stage 3c breast cancer, as the cancer had metastasized to 13 lymph nodes.... Since then, I learned that there are many women like me with recent normal mammogram reports with a hidden intruder stealing their life.  I am on a quest to expose this best-kept secret of dense breast tissue to ensure that women with dense breast tissue receive screening and diagnostic measures to find cancer at its earliest stage - isn't that the purpose of Screening Programs?"

Nancy's story is a widely common one, and demands to be recognized to change the current standards.  We established an advocacy group to help create a new standard protocol for diagnosis because the current standard is clearly an injustice to ALL women. This includes public education and awareness for the many women who get side swiped because of a lack of understanding and clinical information. 

Our advocacy work led us to reach out to our legislators, explore the current insurance coverages and eventually got our first win with a disclosure law in 2009, making Connecticut the first state in the nation to pass legislation making it a law for Docs to disclose to the patient if they have dense breast tissue.   This says that if a woman has dense breasts, she'd must be told by her physician that she's got dense breast there's alternative screening. This includes options like an ultrasound or an MRI.  Also, two years ago, ‘Are You Dense Advocacy, Inc.’ was instrumental in passing the first national dense breast disclosure law. We are now working with Sen. Feinstein to enact this legislation.  

FORGING A NATIONAL MOVEMENT
 
It used to be that when you Googled ‘dense breast’, there was next to NO information available. But over time, as we started making ‘noise’ about this issue, more and more interest began coming our way.  As news broke of our ‘touchdown’ with our state, it wasn’t long before other states started asking how we did it. Before long, Nancy started helping women across the country and the next state was Texas. She helped the girl down in Texas to get legislation passed – and next came our public educational website for the many others who definitely need this.

Nancy quit her job with the state of Connecticut and started doing “Are You Dense” full-time and she helped pass 38 different laws in 38 states.  It's a tremendous amount of work to pass laws on a state by state basis, but she was really the catalyst. Nancy was the person behind and the voice and the face behind dense breast tissue. As outreach work goes, we created a major effort around what we've done now.  Manufacturers are supporting our interest as far as the expansion of full breast automated ultrasound and others came into existence (and are doing quite well) because of our efforts.

* For more information about Nancy and Joe Cappello's national mission, visit: areyoudense.org and areyoudenseadvocacy.org


From the Surgical Side...
"THEY MADE A LAW REQUIRING DENSE BREAST SCANNING"

In New Jersey, we have the Breast Density Law that literally says women with very dense breasts should be getting more than just screening mammography and the insurance companies have to cover. And that can either be an ultrasound or an MRI, but women over 40 do not usually like the idea of getting an MRI and gadolinium IV each year. Instead, adding ultrasound allows you to scan the whole breast and see through the very dense breast tissue. Ultrasounds will also work to the full depth of the breath straight down to the chest wall, so that if there are any masses,  it will see right through the fibers and thick tissue- not limited like mammogram. 

Even extremely dense breast patients should get a mammogram because it also shows things like calcifications-- something that the average ultrasound tech may find harder to capture. Women with extremely dense breast definitely can benefit from added surveillance because as your breasts get more dense, mammography can miss things.  Due to a higher volume of dense tissue, a little tumor can hide underneath fibercystic tissue making it very hard to see in mammography, even with tomosynthesis or the 3d mammo. 

By: Dr. Stephen Chagares | https://www.drchagares.com


TREATMENT OPTIONS
Risk stratification is important since the cost/benefit of any therapy must be weighed against the likelihood of health consequences. Hormone treatments have been controversial for 50 years and remains so to date. Since Dr. Selig Strax (my late partner) developed the “lumpectomy” for conservative therapy of breast cancer at Mt Sinai Medical Center in the 1960’s, advances in limiting tissue damage have yielded progress in chemotherapy, radiation therapy and immunotherapy. Similarly focal treatment options that began with prostate cancer in 2000 with HIFU (High Intensity Focused Ultrasound) are now found in thyroid and breast treatment centers and Laser Ablation and Cryo Ablation are now available alternatives. 

Elastography is used worldwide since 2010 for cancer detection because cancer is hard (inelastic) and benign tissue is soft (elastic).  This quantitative technology for cancer detection has not been adapted for breast density analysis to date.


REFERENCES

1) GE.com/ Setting A New Standard for Breast Care: GE Healthcare Introduces Invenia ABUS 2.0  https://www.ge.com/news/press-releases/setting-new-standard-breast-care-ge-healthcare-introduces-invenia-abus-20#_ftn1

1) Breast density and risk- European Radiology 31:4839-4847, 2021

2) 4D histogram analysis of malignancy-  Mt Sinai Surgical Symposium  2020- 3D/4D breast density histogram
3) Proceedings: Male Breast Cancer Coalition 2019
4) Ultrasound imaging of subdermal pathology /Springer Heidelberg  2018
5) 3D Doppler imaging of malignant melanoma- Intl Dermatologic Surgery Symposium  2016
6) 3D Doppler imaging in dense breasts Proceedings:  2012 Societe Francaises de Radiologie



CONTRIBUTORS

DR. ROBERT L. BARD has paved the way for the diagnostic study of various cancers both clinically and academically. He runs an active NYC practice (Bard Diagnostic Imaging) using the latest in digital Imaging technology which has been also used to help guide biopsies and, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered Sonograms, Spectral Doppler, sonofluoroscopy, 3D/4D Image Reconstruction and the Spectral Doppler are safe, noninvasive, and does not use ionizing radiation. His commitment to lead the community of cancer imaging and diagnostic experts has led to the establishment of the "Get Checked Now!" campaign.

JOSEPH J. CAPPELLO married Nancy Marcucci, in 1974 and the story began.  Joe is the co-founder and executive director of Are You Dense, and Are You Dense Advocacy- in January of 2019 after Nancy’s passing from treatment related bone marrow cancer (MDS). His passion is to continue Nancy’s legacy by pursuing the goal that they set in 2004; that not one woman would die from a late stage breast cancer due to dense breast tissue. In 2009, Joe and Nancy championed the first in the nation breast density inform law in the State of Connecticut (and now, 36 States have breast density legislation).


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DENSE BREAST DETECTION & IMAGE GUIDED ONCOLOGIC TREATMENT

By: Robert L. Bard, MD & Noelle Cutter, PhD   |  Edited by: Lennard M. Gettz, Ed.D PROLOGUE In 2014, Imaging Technology News (ITN) intro...